Bruyère Reports

Executive summary

The objective of this review was to assess the
effectiveness of fall risk screening tools and fall risk assessment tools as a
basis for falls prevention intervention in four settings in continuing care: 1)
palliative care; 2) rehabilitation (geriatric and stroke); 3) long term care;
and 4) short and long term medical care (subacute).

We searched MEDLINE for guidelines and systematic reviews assessing the predictive validity and effectiveness of risk screening and risk assessment tools in these continuing care settings. We found 4 high quality guidelines addressing this question, and 6 systematic reviews of varying quality.

In the four relevant clinical practice guidelines, the utility of using a screening tool for falls risk at admission to classify people as high risk of falling is controversial. The UK NICE 2013 guidelines recommend against using a screening tool and the Australian Commission on Safety and Quality in Health Care (2009) recommend that a full falls risk assessment is more beneficial. In contrast, the Registered Nursing Association of Ontario (RNAO) 2011 updated guidelines recommend falls risk screening with accepted tools such as the Morse or STRATIFY tools followed by a risk assessment to identify modifiable risk factors. Similarly, the American Geriatrics Society (2010) guidelines recommend falls risk screening with 3 questions followed by comprehensive multifactorial risk assessment.

All four clinical practice guidelines recommended a comprehensive multifactorial risk assessment to identify modifiable risk factors for anyone at risk of falling, accompanied by the implementation of interventions tailored to the individual’s identified risk factors. In a companion BBERG report on effectiveness of falls prevention strategies, multifactorial interventions based on risk assessment prevent 7 out of 1000 more falls than control/usual care (RR = 0.69, 95% CI 0.49 to 0.96).

All four clinical practice guidelines recommend that the choice of screening tools and fall risk assessment tools should be guided by the patient’s needs, clinical utility, feasibility for staff, acceptability to patients and similarity of the patient population with the population in which
the instrument was developed or assessed. No single falls risk assessment tool was recommended for these settings because of the need to trade off strengths and limitations that is setting-specific. The six systematic reviews identified 18 risk screening tools and four risk assessment tools that have met the criteria of >70% sensitivity and specificity. These tools are publicly available.

All clinical practice guidelines recommended that staff education and continuing review is important to promote individualized falls risk assessments (updated when needed), to identify modifiable risk factors and implement targeted interventions that are compatible with the client’s risk factors, needs, values, and preferences. Importantly, falls prevention is sensitive for clients and patients because they are associated with loss of independence. Similarly, falls prevention is a sensitive issue for staff because there may be fear of repercussions or blame. Staff and client education can be used to address these barriers to change, and focus on the positive aspects of falls prevention.

Conclusion: Given the diversity of tools and domains assessed and the diversity of patients and clients in the different settings, it may not be possible to select a single tool for all Bruyère settings. We recommend that local implementation teams with clinical expertise and knowledge of each setting are best placed to select the most appropriate tool for their setting, and method of implementing it using a combination of staff and client awareness and education to promote the positive aspects of falls prevention and a culture of continuous learning.

Falls are a major public health problem and the leading cause of injury-related hospitalizations among seniors (aged 65 and older) in Canada; 20 to 30% will experience a fall each year and 85% of all fall-related hospitalizations are due to falls in seniors. Half of adults aged 85 and older will fall each year and 12% to 42% who fall will have a fall-related injury. There are more fall-related hospitalizations associated with serious injuries such as hip fractures in seniors living in long-term residential care (59%) than in the community (32%).The direct health care costs for fall-related injuries in Canada are estimated at $2 billion annually.

Preventing falls was identified by a recent Accreditation Canada report as a high priority. The Senior Quality Committee asked that this review of tools consider the context of each of these different settings with a focus on feasibility, relevance to the setting and validity/reliability.

Risk factors for falls:

Falling is associated with a variety of risk factors including biological, behavioural, environmental and socioeconomic risk factors which are intrinsic (relating to a person’s behavior or condition) or extrinsic (relate to a person’s environment or their interaction with the environment). Many falls occur as a result of interactions of multiple individual and extrinsic risk factors. The most powerful predictor of a fall is a history of falling. Falls can occur in the home or in various hospital settings including continuing care (subacute care) and acute care. Continuing care involves two types of care – residential-based care and hospital-based care. According to CIHI Continuing Care Reporting System 2013-2014 data 9% of assessed residents in residential care are at high risk of falling and 6% of patients in hospital-based continuing care are at high risk of falling in Ontario.

Search process and methods

We searched for relevant systematic reviews and guidelines published between January 2007 and June 2015 in Medline, the Cochrane Library (DARE and HTA) and Trip Database.

We included systematic reviews and guidelines if they assessed the effectiveness of risk screening tools and fall risk assessment tools in predicting falls/identifying falls risk factors in residential-based and hospital-based continuing care populations. We excluded systematic reviews and clinical guidelines if they focused on fracture risk assessment tools or if the population was community-dwelling or the hospital setting focused on acute care.

The search results and potentially eligible articles were screened and reviewed in duplicate. The quality of guidelines and systematic reviews were assessed using the AGREE score and AMSTAR checklist respectively.

Guidelines on risk screening and risk assessment

We identified 4 guidelines that met our inclusion criteria: the Canadian Registered Nurses' Association of Ontario (RNAO) guidelines, the UK National Institute for Health and Care Excellence (NICE) guidelines, the Australian Commission on Safety and Quality in Health Care (ACSQH) guidelines and the American Geriatrics Society (AGS) guidelines with evidence on screening tools and falls risk assessment. The guidelines were of high quality scoring 160 -168/168 on AGREE II.

Risk screening:

NICE - Not recommended [level III evidence] since time intensive and no more effective than clinical judgment. Also all patients have a high risk of falling because of their medical their medical condition, a change in their environment and their age (65 years or older).

ACSQH - Recommended on admission, when there is a change in the health and functional status of the individual or when the patient’s environment changes. If an individual is at high risk on admission (e.g. with a history of previous fall or medical condition) consider using multifactorial risk assessment instead to identify modifiable risk factors. Some examples of validated tools for the hospital setting are STRATIFY, Downton index and Morse scale. Should be done by a staff member who understands the process and can administer the tool, interpret the results and make referrals where indicated. Using validated screening tools as part of routine clinical management can inform care and future assessment of patients/residents.

AGS - Recommended risk screening with three questions: 1) History of fall in 12 months; 2) presenting with an acute fall; or 3) difficulty with walking or balance.

Comprehensive risk assessment:

NICE - Recommended only if linked to multifactorial intervention to reduce risk of falls based on risk assessment [level III evidence.] Choose tools and domains based on setting and population

RNAO - Further assessment is performed by clinicians with the appropriate knowledge, skills, and training if the initial screening indicates fall risk factors. Choose tool appropriate for setting and population

ACSQH - Recommend. Choose tool based on setting and population. Multidisciplinary team recommended with one coordinator.

AGS - Recommend for those with history of falls or gait/balance problems. No tool recommended, multiple domains suggested.

RNAO: Registered Nurses’ Association of Ontario, Canada
ACSQH: Australian Commission on Safety and Quality in Health Care
AGS: American Society of Geriatrics*

Guidelines on multifactoral risk

All four guidelines recommend some type of multifactorial risk assessment linked to a tailored, individual plan for falls prevention which could address modifiable risk factors (e.g. deprescribing medications, strengthening exercises, environmental modifications, etc based on the assessment).

There is no agreement on which risk assessment tools are best for particular settings. All guidelines suggested that tools and/or domains need to be chosen based on the setting and patient population.

The 5 tools identified as having evidence of benefit in prospective studies as part of a falls prevention program are:

Care plan assessment items for the acute setting

FRAT for the subacute and rehabilitation setting

PJC FRAT for the subacute and rehabilitation setting

Falls risk for hospitalized older people (FRHOP) tool for the subacute and rehabilitation setting

MDS-RAI for long term care.

These tools vary in the number of risk factors they include and how each factor is assessed. A multidisciplinary team should do the assessment where possible or a skilled staff person.

Regarding subacute, rehab, long term care, palliative, we found that specific tools have been developed in these settings:

Subacute/rehab – FRAT, PJC-FRAT, FRHOP,

Long term care – MDS-RAI

Palliative – FRASE tool but did not meet the 70% predictive accuracy criteria.

Some tools consist of sub-domains to assess specific risk factors and these may involve the use of additional validated tools and measures such as the Timed Up and Go Test or the Functional independence measure (FIM) for assessing balance/gait problems.

We identified 6 systematic reviews. The quality of the systematic reviews varied. One review each had an AMSTAR score of 7/11, 6/11, 5/11, 3/11; and two scored 2/11.

In these 6 systematic reviews, 23 screening tools and 10 falls risk assessment tools for both residential-based and hospital-based continuing care were assessed for prediction of falls. Only one review assessed the time to administer the tool and if training was required to administer the tool. Only 18 falls screening tools and four risk assessment tools met the criteria of >70% for specificity and sensitivity proposed by NICE.

Four tools could be used for both screening and falls risk assessment: the Fall assessment questionnaire, Falls Risk Assessment Tool (FRAT), the Peter James Centre Fall Risk Assessment Tool (PJC-FRAT) and the Resident Assessment instrument (MDS-RAI).

Falls risk screening tools:

All the systematic reviews assessed the predictive accuracy of different tools and four screening tools met the high predictive accuracy criteria and were assessed in 3 or more systematic reviews: the St Thomas Risk Assessment Tool in Falling Elderly In-patients (STRATIFY), Morse Fall scale, Hendrich II Fall Risk model and clinical judgment. These have been recommended for use on admission or after a fall in the RNAO guidelines to identify people at high risk of falling.

One review also considered the time it took to administer the different tools and if training is required to administer the tool.

Falls risk assessment:

Four falls risk assessment tools met these criteria of 70% for sensitivity and specificity and were assessed in 2 or more systematic reviews:

Discussion: strengths and limitations

Strengths of this review are a systematic search for the evidence, assessment of relevance to specific settings and assessment of quality using validated tools

Limitations of this review are that the underlying evidence base is low quality, dispersed, and there is disparity among guideline panels about whether to use a falls risk screening tool, and about the content of a multifactorial risk assessment tool.

There is disparity around what factors to include in the risk assessment process. A brief assessment could be done for a specific risk factor or for those at low risk (e.g. balance and mobility could be assessed using the TUG test in the outpatient setting); a more comprehensive assessment for high risk patients may require referral to a geriatrician.

There is scarcity of evidence regarding the use of falls risk assessment tools across different settings. For example, only one tool, the Falls Risk Assessment Scale for the Elderly (FRASE), was assessed in palliative care but did not meet the predictive accuracy cutoff point of 70%. A systematic review of palliative care settings suggested that different risk factors are prevalent in palliative care, thus requiring tailored risk assessment and intervention.

The MDS risk assessment instrument is widely recommended for use in long term care. Although it contains risk factors for falling, there is no clear pathway to specifically identify patients at risk.

Implementation

The choice of screening tools and risk assessment tools should be guided by the patient’s needs, clinical utility, feasibility for staff, acceptability to patients and similarity of the patient population with the population in which the instrument was developed or assessed, the predictive accuracy of the tool. Healthcare organization leaders should also consider training of staff to use the tool, potential staff acceptance and adherence which could be influenced by the length of time for completing the assessment. The length of time for completing the assessment varied from less than one minute (for the TUG test, Hendrich fall risk model and Morse fall scale) to 80 minutes (for Resident assessment instrument in long-term residential care).

There is no consensus on which falls risk factors should be included in falls screening and risk assessment tools. Some tools are more specific for some risk factors. For example, of the high predictive accuracy tools, five tools were intended for impaired balance and mobility: Berg Balance test, Timed up and go (TUG) test, Tinetti performance oriented mobility scale, Elderly fall screening test, Dynamic gait index.

Recommendations

From our review, we suggest the following recommendations.

Tools should be tailored to the needs of the patient population. The choice should be guided by clinical utility, feasibility for staff, acceptability to patients/clients and similarity of the patient/client population with the population in which the instrument was developed or assessed.

Bruyère Continuing Care should develop an organizational policy to conduct a comprehensive falls risk assessment for anyone considered at risk of falling, tailored to the client population and setting and implement multifactorial interventions that are compatible with the client’s risk factors, needs, values, and preferences.